Fillable Profile For Credentialing - Delta Dental (Page 2 of 2) in pdf

Dentist

Profile for Credentialing

(Must be completed in its entirety)

Last Name: ________________________________ First Name: ______________ MI:_____ o Male o Female

Individual NPI #: __________________ Social Security #: _________________ Date of Birth: _____________

(Type 1)

Please indicate which license #

Office Address: ______________________________________________

is used on insurance claim forms.

o General

o Specialty

General License #: _____________ Specialty License #: _____________

DEA Eligible: o Yes o No If no, please attach explanation. DEA#: __________ Expiration Date: __________

Controlled Substance Eligible: o Yes o No If no, please attach explanation.

Controlled Substance #: ____________________ Expiration Date: _________________

Dental School:_________________________ City/State:________________________ Year Graduated:______

Degree:

o DDS

o DMD

o Other: _____________________ Specialty Type: ___________________

Specialty Dental School: _________________________ City/State: __________________________________

Year Graduated: __________

Delta Dental of Illinois (DDIL) Minimum Liability Insurance Requirements:

PLEASE NOTE THAT WE REQUIRE DENTISTS WHO PERFORM SURGICAL PROCEDURES, HIGH RISK

PROCEDURES, AND/OR ADMINISTER ANESTHESIA OR IV SEDATION TO CARRY $1 MILLION PER

OCCURRENCE AND $3 MILLION IN THE AGGREGATE. You must attach a copy of the declaration page of

your Liability Policy.

Indicate your Liability Insurance Amounts: Per Occurrence $ ____________ Aggregate $ _____________

If you carry less than $1 Million per Occurrence and $3 Million in the Aggregate please sign below:

I certify that I do not perform surgical procedures, high risk procedures and/or administer anesthesia or

IV sedation.

Dentist Signature: __________________________________

Date: ___________________

Attestation: Please answer the questions below: (When indicated, please attach the explanation(s) to

this form).

1. Are you currently or have you been involved in

7. Is your office in compliance with OSHA?

any malpractice or litigation proceedings?

If no, please explain.

o Yes o No

If yes, please explain.

8. Do you use paraformaldahyde (Sargenti

2. Has your license ever been denied, revoked or

Method) in RCT?

suspended?

o Yes o No

If yes, please explain.

9. Have you ever had a claim reported to the

3. Have you ever been disciplined by any state or

National Practitioner Data Bank?

local licensing board(s)?

If yes, please explain.

o Yes o No

If yes, please explain.

10. Are you in compliance with the Center for

4. Has your DEA permit ever been denied or

Disease Control and Prevention (CDC)

revoked?

o Yes o No

If yes, please explain.

guidelines on infection control practices

5. Have you ever been convicted of a felony or

for dentistry?

federal offense?

o Yes o No

If no, please explain.

If yes, please explain.

o Yes o No

11. Are you currently or have you been sanctioned

6. Do you have an illness, defect or addiction that

by the Office of Inspector General (OIG),

interferes with you practicing dentistry with or

Medicare or Medicaid?

without accommodations?

o Yes o No

If yes, please explain.

o Yes o No

I will allow DDIL to consult with and inspect documents from individuals and organizations having information regarding

my qualifications, attestation and work history. The information provided herein is true and correct and may be relied

upon as accurate by any person and or entity. I agree to notify DDIL within 30 days of any changes to my license status,

attestation answers and liability coverage or if I commence or cease performing surgeries and/or administering anesthesia

or IV sedation.

Dentist Signature (Required) _______________________________________

Date: _______________________

For Administrative Use Only: License(s) o - NPI(s) o - DEA o or Explanation o - OIG o - Liability Insurance o Completed Attestation o - Attachments _______________

Dentists Signature o Date o - Verified by & Date: ________________________ Entered by & Date: ____________________________

7390 (10/15)

Profile For Credentialing - Delta Dental Page 2

Related Articles

Related forms

Related Categories